What Are Stomach Ulcers and How Do They Form?
A stomach ulcer, also called a peptic ulcer, is an open sore that develops on the inner lining of your stomach or the upper part of your small intestine. The stomach naturally produces acid to break down food and kill bacteria, but this acid is protected by a thick layer of mucus that lines the stomach wall. When this protective mucus layer becomes damaged or thins out, the acid can eat away at the tissue underneath, creating a wound or ulcer.
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Think of it like a blister on your skin, except it's happening inside your digestive system where stomach acid constantly bathes the area. These ulcers can range in size from small pinhead-sized spots to larger sores that are several inches across. Some ulcers stay on the surface of the stomach lining, while others can burrow deeper into the tissue layers below.
The formation of an ulcer typically takes time and involves repeated exposure to whatever is damaging the protective mucus layer. It's not something that happens overnight in most cases. As the ulcer develops, you may not notice any symptoms at first, especially if it's small. However, as it grows larger or if acid continues to irritate the open wound, pain and other symptoms usually develop.
Research shows that approximately 1 in 10 Americans will experience a peptic ulcer at some point in their life. Men develop ulcers more frequently than women, and they tend to occur more often in people over 60 years old, though they can happen at any age. Understanding how ulcers form helps explain why certain risk factors put some people at higher risk than others.
Practical takeaway: Stomach ulcers develop when the protective mucus lining becomes damaged, allowing stomach acid to create an open sore. Knowing this helps you understand why the causes and treatments target either reducing acid or protecting the remaining mucus layer.
Helicobacter Pylori Bacteria: The Leading Cause
Helicobacter pylori, commonly called H. pylori, is a bacterium that lives in the stomach lining and is responsible for causing approximately 60% of all peptic ulcers worldwide. This spiral-shaped bacteria produces chemicals that weaken the protective mucus layer, allowing stomach acid to damage the underlying tissue. H. pylori can survive in the harsh acidic environment of the stomach because it produces an enzyme called urease that neutralizes the acid around it, creating a safe zone where it can live and reproduce.
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H. pylori infection is spread from person to person, typically through contaminated food or water, or through direct contact with saliva or other body fluids. In developing countries with poorer sanitation, infection rates can reach 50% or higher in the general population. In developed countries like the United States, the infection rate is lower but still significant, affecting roughly 20% of people under age 40 and up to 50% of people over age 60.
Many people infected with H. pylori never develop ulcers or experience any symptoms. The bacteria can live quietly in the stomach for years without causing problems. However, when it does trigger ulcer formation, it can lead to chronic pain, bleeding, and other serious complications. The reason some infected people develop ulcers while others don't involves genetics, the specific strain of bacteria, and other environmental factors not yet fully understood.
Doctors can test for H. pylori infection using several methods. A breath test involves drinking a special liquid and then breathing into a bag that detects the byproducts of the bacteria. A blood test can detect antibodies your body produced in response to the infection. A stool test can identify bacterial particles. An endoscopy, where a thin tube with a camera is inserted down the throat, allows doctors to take a tissue sample directly from the stomach for testing. Once detected, H. pylori can be treated with a combination of antibiotics and acid-reducing medications, which can heal ulcers and prevent them from returning.
Practical takeaway: H. pylori bacteria cause most peptic ulcers by damaging the protective stomach lining. Testing can determine if you're infected, and antibiotics can eliminate the bacteria, allowing ulcers to heal.
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) as a Major Risk Factor
Nonsteroidal anti-inflammatory drugs, or NSAIDs, are responsible for approximately 25% of all peptic ulcers. This category includes over-the-counter medications like ibuprofen (Advil, Motrin), naproxen (Aleve), and aspirin, as well as prescription-strength versions. NSAIDs work by blocking enzymes called cyclooxygenases that produce prostaglandins, which are hormone-like substances that both reduce pain and inflammation and protect the stomach's mucus lining. While NSAIDs effectively reduce pain and inflammation throughout the body, this same mechanism that blocks pain also reduces the stomach's natural protection against acid.
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The risk of developing NSAID-related ulcers increases significantly with several factors. Taking NSAIDs regularly or in high doses substantially raises your risk compared to occasional use. Older adults, particularly those over age 65, face a much higher risk than younger people, with studies showing that seniors taking NSAIDs regularly have ulcer rates three to four times higher than younger users. Having a personal or family history of peptic ulcers also increases your vulnerability. Additionally, being infected with H. pylori while taking NSAIDs dramatically increases ulcer risk, sometimes by five times or more, because both factors are working against the stomach lining's protection.
Other conditions and medications can compound NSAID-related ulcer risk. People taking corticosteroids, certain blood thinners, or low-dose aspirin for heart protection face higher risk when combined with NSAIDs. Smoking and heavy alcohol consumption also increase susceptibility. Interestingly, H. pylori infection and NSAID use don't just add together—they multiply the risk. A person with both factors may have significantly higher ulcer risk than someone with just one factor.
People who need to take NSAIDs regularly for chronic pain conditions like arthritis have options to reduce their ulcer risk. Doctors can prescribe a class of medications called proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2 blockers) that reduce stomach acid production, protecting the lining while NSAIDs are being used. Switching to acetaminophen for pain relief when possible, using the lowest effective NSAID dose for the shortest duration necessary, and taking NSAIDs with food may all help reduce risk.
Practical takeaway: NSAIDs reduce pain but also damage stomach protection, causing 1 in 4 ulcers. People taking these medications regularly, especially older adults, should discuss ulcer prevention strategies with their doctor.
Other Causes and Contributing Risk Factors
While H. pylori and NSAIDs account for roughly 85% of peptic ulcers, other causes and risk factors can lead to ulcer development. Stress-related ulcers, sometimes called stress ulcers, can develop during periods of severe physical or emotional stress. Historically, doctors believed psychological stress was a major cause of ulcers, but modern research has shown that stress alone typically doesn't cause ulcers in healthy people. However, stress can worsen existing ulcer symptoms and may reduce the body's ability to heal. Severe physical stress, such as from major surgery, severe burns, or critical illness, can trigger ulcer formation even without H. pylori or NSAID use.
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Zollinger-Ellison syndrome is a rare condition where a tumor in the pancreas or small intestine produces excess gastrin, a hormone that stimulates stomach acid production. This dramatically increased acid production overwhelms the stomach's protective mechanisms and causes severe, often multiple ulcers. Crohn's disease, an inflammatory bowel condition, can occasionally cause ulcers in the stomach or duodenum as part of the disease process. Severe liver disease (cirrhosis), kidney failure, and lung disease can all increase ulcer risk through various mechanisms.
Lifestyle factors significantly influence ulcer development and healing. Smoking reduces the protective mucus layer, impairs blood flow to the stomach lining, and increases acid production—all factors that promote ulcer formation and slow healing. Smokers have approximately twice the risk of developing ulcers compared to nonsmokers and experience slower ulcer healing. Heavy alcohol consumption irritates the stomach lining and can increase acid production. While occasional